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A single-blind pilot study to determine risk and association between navicular drop, calcaneal eversion, and low back pain.
Brantingham JW, Adams KJ, Cooley JR, Globe D, Globe G. J Manipulative Physiol Ther. 2007 Jun;30(5):380-5.
Quote:
OBJECTIVE: Syndromes causing mechanical low back pain (MLBP) continue to plague the US health care system. One hypothesis is that flatfeet are a risk factor for MLBP. This pilot study evaluated whether subjects with flatter feet are at greater risk for MLBP than subjects without flatter feet.
METHODS: Fifty-eight subjects (16-70 years old) were allocated to a group diagnosed with 2 or more episodes of MLBP or with no history of MLBP. A blind assessor measured navicular drop (ND) using navicular height (NH) and calcaneal eversion (CE). Based on a range of reported data, flatfoot was defined as a possible risk factor for MLBP with ND greater than 3, 8, and/or 10 mm, and/or greater than 6 degrees CE.
RESULTS: According to chi2 analysis, risk of MLBP appeared similar between groups (P > .05). There was no significant difference (P > .05) between continuous variables (t tests, Pearson r and r2) with one exception, correlation of increasing CE with increasing ND (P = .0001). Power was generally low (<0.80). Likelihood ratios and Fisher exact tests supported the chi2 analysis.
CONCLUSIONS: In this study, flatfeet did not appear to be a risk factor in subjects with MLBP. However, small sample size, low power, broader age range, low prevalence of flatfeet (>10 mm ND), and lesser back pain severity make these data tentative. Further research is needed.
flatfeet did not appear to be a risk factor in subjects with MLBP
Quote:
small sample size, low power, broader age range, low prevalence of flatfeet (>10 mm ND), and lesser back pain severity make these data tentative
....so why was it even accepted for publication?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Bilateral and unilateral increases in calcaneal eversion affect pelvic alignment in standing position.
Pinto RZ, Souza TR, Trede RG, Kirkwood RN, Figueiredo EM, Fonseca ST. Man Ther. 2007 Sep 29; [Epub ahead of print]
Quote:
Excessive foot pronation has been associated with the occurrence of low back pain, possibly for generating changes in the lumbopelvic alignment. However, the influence of foot pronation (measured as calcaneal eversion) on pelvic alignment during standing has not been well established. Fourteen young healthy subjects participated in the study. A Motion Analysis System was used to obtain pelvic positions in sagittal and frontal planes and calcaneal position in the frontal plane. Volunteers were filmed in relaxed standing position during three trials, in three conditions: control; unilateral experimental with increased right calcaneal eversion and bilateral experimental with increased bilateral calcaneal eversion. Increased calcaneal eversion was obtained using wedges tilted 10 degrees medially, unilaterally and bilaterally. Repeated measures ANOVAs with Bonferroni corrections were used for statistical analysis. Unilateral and bilateral use of medially tilted wedges produced a significant increase of calcaneal eversion (P0.01), on the right and left sides. Bilateral and unilateral increases of the calcaneal eversion caused average pelvic anteversion of 1.57 degrees (P=0.003) and 1.41 degrees (P=0.021), respectively. Unilaterally increased everted position generated an average pelvic lateral tilt of 1.46 degrees (P<0.001). Excessive calcaneal eversion during standing changes pelvic alignment and should be considered, associated with other relevant factors, when assessing pelvic misalignments.
There was also this from January: Effect of feet hyperpronation on pelvic alignment in a standing position.Khamis S, Yizhar Z. Gait Posture. 2007 Jan;25(1):127-34
Quote:
Hyperpronation may cause malalignment of the lower extremity, frequently leading to structural and functional deficits both in standing and walking. Our aim was to study the effect of induced foot hyperpronation on pelvic and lower limb alignment while standing. Thirty-five healthy subjects were requested to remain in a natural standing position for 20s in four different modes: feet flat on the floor, and on wedges angled at 10 degrees, 15 degrees and 20 degrees, designed to induce hyperpronation. Sequencing was random, repeated three times and captured by eight computerized cameras using the VICON three-dimensional motion analysis system. We found that standing on the wedges at various angles, induced hyperpronation, with 41% to 90% of the changes attributable to the intervention. In addition, a statistically significant increase (paired t-test) in internal shank rotation (p<0.0001), internal hip rotation (p<0.0001) and anterior pelvic tilt (p<0.0001) was identified. A strong correlation was found between segmental alignment in every two consecutive modes at all levels (r=0.612-0.985; p<0.0001). These findings suggest that alignment of the lower extremity up to the pelvic girdle, can be altered, due to forces acting on the foot. Interaction between the foot and pelvis occurs in a kinematic chain reaction manner. Although this study was limited to healthy subjects, clinicians should be aware that when addressing pelvis and lower back dysfunction, foot alignment should be examined as a contributing factor.
The importance of the feet to the normal biomechanical functioning of the spine often is overlooked. Because the feet are seldom symptomatic, busy chiropractors frequently overlook examining and, consequently, treating them. Often times, it’s only when a patient does not respond as well as expected to care that the chiropractic physician begins to look for interference from the pedal foundation. Faulty foot biomechanics can have a negative impact on all supporting joints above the foot/ankle complex. A recent study concluded, “There are small, but important, intersegmental movements of the spine during gait.”1 Furthermore, an abnormal gait (no matter what the source) eventually will interfere with these important spinal segmental movements. This, in turn, can lead to serial postural distortions, muscular imbalances and spinal joint dysfunction.
The Foot/Spine Connection
When we stand, walk, dance, jump and run, the feet are the foundation to the spine and the rest of the musculoskeletal support system of the body. This foundation must bear the weight of the entire body. If there is insufficient support from the pedal foundation, the spine will be exposed to less than optimal gait mechanics, which eventually can cause spinal joint dysfunction, postural deviations and back pain. Recognizing and responding appropriately to faulty foot biomechanics will allow chiropractic physicians to more effectively care for their patients.
Abnormal stresses on the pelvis and spine can be the result of, but not limited to, excessive shock transmission, abnormal joint motion, abnormal foot proprioception or a functional short leg. The cause of all four of these problems often is located in the feet. When a part of the foot is not moving properly (either insufficient or excessive joint motion), the resulting forces produce effects along the whole kinetic chain. Researchers have found, “Alteration of normal foot mechanics can adversely influence the normal functions of the ankle knee, hip and even the back.”2
Shock Transmission
In ideal standing, posture with even feet forms an angle of 30 degrees and a plumb line dropped from the sacral promontory falls midway between the feet onto a line between the navicular bones.3 Pronation occurs when the superior aspect of the calcaneus tilts and rolls inward, which then brings the talus with it. This releases the navicular from arthrodial articulation with the talus and jeopardizes the medial longitudinal arch. When collapsed, it can begin serial distortion that may extend to the occiput.4 If the biomechanics of a foot tend to function in either hyperpronation or excessive supination, excessive shock is transmitted to the spinal joints. A high arched or cavus foot with limited range of motion attenuates shock poorly, and a hypermobile flat foot also does poorly on shock attenuation because of its function near the end of the range of motion.5 In either case, the forces may be felt in the joints of the pelvis and spine. In fact, enhancing shock absorption from the lower extremities may be one of the most significant long-term improvements that will be reported by patients with degenerative discs and spinal joints.
Light and his colleagues studied the “brief but sizeable deceleration transient, which travels up the human skeleton on heel strike during normal walking.”6 In their classic investigation, they found significant stress that could be reduced with the use of visco-elastic heel pads. Regarding the spine, they warned, “While the transients will load the majority of joints primarily in compression, shear stress will predominate in others, such as spinal facet and sacroiliac joints.”6 This may explain the rapid response of lumbosacral and sacroiliac pain with the use of orthotics that contains shock-absorbing materials.
Abnormal Joint Motion
When the foot and ankle biomechanically function in prolonged pronation, the entire lower extremity undergoes excessive internal rotation. This causes a range of altered biomechanics in the pelvis, sacroiliac joints and spine. Hammer has described the numerous consequences as follows: “Based on excessive internal femoral rotation due to hyperpronation, this may develop compensatory shortening of the iliopsoas, which would draw the spinal column downward, forward and rotate contralaterally. Unilateral iliopsoas involvement would cause a unilateral anterior pelvic tilt, while bilateral hyperpronation may result in an increased lordosis.”7 The result is recurring abnormal joint motion affecting the sacroiliac and lumbar spine joints. These forces can be decreased significantly with the use of an orthotic that controls hyperpronation.8
Altered Proprioception
Proprioceptors are the sensory organs located in muscles and joints that provide information to the central nervous system regarding the status, function and position of the musculoskeletal system. With several small joints, ample layers of connective and articular tissues, and both intrinsic and extrinsic muscles, the feet are very well supplied with proprioceptive nerve endings. When there is biomechanical dysfunction, it is probable that inaccurate neurologic information is sent to the CNS from the feet. This can have a detrimental effect on coordination and balance throughout the spine and pelvis.9
Dropped Pelvis
When there is a discrepancy in the length of the legs (whether anatomical or functional), the pelvis is lower on one side. Leg-length asymmetry will cause vertebral rotation, recurrent subluxation and possibly a functional scoliosis, which in turn, produces strains to the pelvic and low back structures. These strains can cause not only chronic pain10,11 but also have been shown to result in specific degenerative changes.12 The most common cause of a functional short leg is a lowered medial arch and excessive pronation. The study by Rothbart and Estabrook found a correlation factor of 0.97 between asymmetrical pronation and a pelvic tilt to the same side.13 Because of these types of findings, it may be difficult to eliminate pelvic and spinal dysfunction without treating the feet.
What to Do
Every patient with spinal and pelvic-joint dysfunction should be checked for abnormal foot biomechanics. This evaluation can be quick and easy and is not painful to the patient. The feet may need to be adjusted so that numerous joints up the kinetic chain can move smoothly during each phase of gait. In addition, most patients with biomechanical foot problems will benefit from the long-term support provided by orthotics.
Conclusion
When a patient presents with spinal joint dysfunctions, especially ones that do not correct rapidly and completely, a search for contributing factors must include examination of the feet. Orthotics can be helpful in most cases needing long-term spinal stabilization. Even expertly applied, spinal corrections often will be only partially successful until the lower extremity problems are uncovered, corrected and supported for the long haul.
Positional relationship between leg rotation and lumbar spine during quiet standing.
Parker N, Greenhalgh A, Chockalingam N, Dangerfield PH. Stud Health Technol Inform. 2008;140:231-9.
Quote:
Healthcare professionals frequently evaluate spinal posture on visual assessment during the clinical examination. While this visual assessment of the spine has been shown to be unreliable, the use of a plumbline as to aid clinical visual assessment has also been reported. There is a "normal" sagittal contour that functions quite well in healthy people. It positions the head in space, it protects the neural axis, and it allows efficient, pain-free motion. Lumbar lordosis is routinely evaluated in most spine patients, but what constitutes a normal sagittal contour is less well defined. A key component of normal sagittal contour is lumbar lordosis. Changes in the lumbar lordosis frequently occur in pathological gait, usually in association with alterations in pelvic tilt, and commonly as a compensation for a limited range of flexion/extension at the hip joint. Recent investigations looked at the effect of hyperpronation on pelvic alignment in a standing position and supported the existence of a kinematic chain in healthy subjects, where hyperpronation can lead to an immediate shank and thigh internal rotation and change in pelvic position. While there is a wealth of research is available on the effectiveness of functional foot orthoses, the present investigation reports the effect of pronated foot position on the lumbar region of the back by employing an optoelectronic movement analysis system.
Some good Data here. But a long way from indicating the kinematic chain theory can be relied upon to treat LBP.
Firstly a correlation between LBP and foot posture does not indicate a causal link in either direction!
Also i think we must be aware of the perils of over extrapolation. Placing an eversion wedge under the foot may well affect a rotational change in the leg, however the foot in relaxed stance will already be at maximum passive pronation in most cases. What would be more interesting would be to put the same wedge to invert the foot and compare the difference THAT makes.
I'm not saying there is not a link between foot posture and LBP mind you. I just feel that the evidence we have to support the kinetic chain model is flawed and the evidence for the kinematic chain even more so!
Why have these studies worked with either demographic data (which may establish correlation but not causality) and induced hyperpronation? Given the point of these studies is to consider the relevance of insole why simply compare relaxed stance spinal / pelvic position with the position wearing insoles?
I beleive that insoles can have a positive effect on LBP but i think we need a better understanding of why and induceing hyperpronation to indicate the kinematic chain smacks of a study designed to prove the hypothesis rather than to disprove it to me.
Is motion control a dirty word in podiatry? It seems motion control has been sold to the physio world without any evidence.... Im sure Ive seen changes in the clinic in regards to lower limb int/ext rotation with fairly basic orthotics. Was I imagining this???
Is motion control a dirty word in podiatry? It seems motion control has been sold to the physio world without any evidence.... Im sure Ive seen changes in the clinic in regards to lower limb int/ext rotation with fairly basic orthotics. Was I imagining this???
Off course it has. Motion dosen't hurt. Forces hurt. Its all about force contral and not motion control (see this thread, among many others - esp pages 2 & 3).
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Dear Craig thanks for the rapid reply.
The shift of asessment as stated by Kevin Kirby in that forum is obviosly abour kinematics. Its great to be able to access leading health professionals brains , Im not aware of an equivalent site for physios.
I know this topic has been thrashed to bits but I would like to put my 2c in.Maybe an opinion from a manual therapist may be of interest.If no one replies Ill assume I need to do much more reading....
Kevin States
"Simon has very nicely provided an analysis of the tissue stress theory of mechanical foot therapy. The key points of the tissue stress theory of mechanical foot therapy is that the clinician should first identify the anatomical structure that is the cause of the pain/pathology, then determine the structural/functional factors that are the cause of the pain/pathology, and finally design a treatment plan that will reduce the pathological stresses on the injured tissue and will improve gait dynamics, without causing other injuries/symptoms.
One cannot separate kinetics from kinematics in biomechanics. Changes in kinetics cause a change in kinematic function. Therefore, if one identifies a change in kinematic function, then one also knows that the kinetics has changed. However, if there is no change in kinematic function, one can not also presume that there is no change in kinetics, since, as Simon notes, the internal forces and internal moments may have changed with no apparent change in joint position."
Im a myofascial therapist and we are always trying to normalise muscle function by needling or releasing muscles that have fibrosed due to mechanical strain. Commonly the lateral fascial line gets locked short/ tight and weak with pronated feet (TFL,ITB,PeL,PeB etc) THis serves to inhibbit FHL,TPost,etc. The latter being in a mechanically weaker position.I was taught that a muscles optimal output and therefore its most efficient function is halfway from its maximally lengthened position and its shortest position. This position being "ideal posture".
It was my understanding that an orthotic put the foot into this position. Clinically attention to the muscles above mentioned changed a persons posture (kinetics)in combination with orthotic therapy.
This muscle balance theory is the cornerstone to myofascial therapy which can be applied to all joints of the body,and we expect visual changes????
Regards Gavin J
There are a couple around (eg PhysioBob) and I occasionaly check them out, but they never really get into some topics like we do here (every forum has its "characteristics")
Quote:
I was taught that a muscles optimal output and therefore its most efficient function is halfway from its maximally lengthened position and its shortest position. This position being "ideal posture".
Never heard any evidence to support that and I fail to see how it can be true - every muscle would have to be different depending on its relationship to the axes of the joint that it crosses, I would have thought.
Quote:
It was my understanding that an orthotic put the foot into this position.
We use to think thats what we were trying to achieve, but the evidence is pretty clear that this does not happen (and when it does happen, its not correlated to clinical outcomes).
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Dear Craig thanks for the rapid reply.
The shift of asessment as stated by Kevin Kirby in that forum is obviosly abour kinematics. Its great to be able to access leading health professionals brains , Im not aware of an equivalent site for physios.
I know this topic has been thrashed to bits but I would like to put my 2c in.Maybe an opinion from a manual therapist may be of interest.If no one replies Ill assume I need to do much more reading....
Kevin States
"Simon has very nicely provided an analysis of the tissue stress theory of mechanical foot therapy. The key points of the tissue stress theory of mechanical foot therapy is that the clinician should first identify the anatomical structure that is the cause of the pain/pathology, then determine the structural/functional factors that are the cause of the pain/pathology, and finally design a treatment plan that will reduce the pathological stresses on the injured tissue and will improve gait dynamics, without causing other injuries/symptoms.
One cannot separate kinetics from kinematics in biomechanics. Changes in kinetics cause a change in kinematic function. Therefore, if one identifies a change in kinematic function, then one also knows that the kinetics has changed. However, if there is no change in kinematic function, one can not also presume that there is no change in kinetics, since, as Simon notes, the internal forces and internal moments may have changed with no apparent change in joint position."
Im a myofascial therapist and we are always trying to normalise muscle function by needling or releasing muscles that have fibrosed due to mechanical strain. Commonly the lateral fascial line gets locked short/ tight and weak with pronated feet (TFL,ITB,PeL,PeB etc) THis serves to inhibbit FHL,TPost,etc. The latter being in a mechanically weaker position.I was taught that a muscles optimal output and therefore its most efficient function is halfway from its maximally lengthened position and its shortest position. This position being "ideal posture".
It was my understanding that an orthotic put the foot into this position. Clinically attention to the muscles above mentioned changed a persons posture (kinetics)in combination with orthotic therapy.
This muscle balance theory is the cornerstone to myofascial therapy which can be applied to all joints of the body,and we expect visual changes????
Regards Gavin J
Gavin:
Good to have you join in on our discussions. Even though foot orthoses may or may not noticeably change the position of the osseous structures of the foot, they may still have a therapeutic effect. Sometimes I see rather large changes in gait kinematics with foot orthoses, and other times I see minimal to no change in gait kinematics with foot orthoses in my patients. Certainly there is plenty of scientific research that clearly shows that foot orthoses changes gait kinematics, both in running and walking. However, the research also shows that the changes in kinematics are much less than the changes in kinetics.
It would be difficult to say that foot orthoses by themselves "change posture" unless that means "foot posture" specifically. I do see in my clinic, however, that foot orthoses may dramatically change the angle and base of gait, the stride length, the length of the propulsive phase of gait and the position of the ankle, subtalar and midtarsal joints during both the stance and swing phases of walking gait.
In regards to changes in muscle moment arms, foot orthoses may also signficantly affect these. For example, in the case of the subtalar joint (STJ), if the orthosis moves a foot from the maximally pronated to a less pronated STJ position, both the anterior tibial and posterior tibial muscles will have increased supination moment arm lengths relative to the STJ axis than they would have had without the foot orthosis intervention.
Even though these changes in muscle moment arm lengths do occur sometimes due to a change in joint position with foot orthoses, the major mechanical effect of foot orthoses on the human body is rather to change the point of application, magnitude and temporal patterns of ground reaction forces acting on the plantar foot during weightbearing activities. This is the change in kinetics that is so important in producing the internal mechanical effects on the structural components of the foot and lower extremity that cause not only the change in kinematics we may or may not see, but also the change in subjective complaints that we very commonly see with foot orthoses.
Good to have you contributing and hope this helps.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
A single-blind pilot study to determine risk and association between navicular drop, calcaneal eversion, and low back pain.
Brantingham JW, Adams KJ, Cooley JR, Globe D, Globe G. J Manipulative Physiol Ther. 2007 Jun;30(5):380-5.
This is interesting to me because I do know one of the authors of this study, Dr. Gary Globe. He headed our clinic at Cleveland Chiropractic College when I was an intern and I do not recall assessment of the feet or gait analysis being a part of the clinical analysis or requirement of our clinical experience. I am interested in who funded that study and when they adopted an interest in the lower extremity, which was severely, absent during my clinic rounds.
I do understand the relevance of an inquiry into the relationship between hyperpronation and the prevalence of mechanical low back pain. The premise of this study is to assess if there is causal link between patients with flatfoot based on calcaneal eversion and measurable navicular drop and that pathological pronation is a contributing factor in mechanical LBP.
I know that Foot Levelers has marketed its product to my profession based on an assumption that there is a causal link between foot position and changes further up the kinetic chain. Their entire paradigm is built upon their assertion that even asymptomatic patients require “spinal pelvic stabilizers” to optimize the relationship between the lower extremity and the spine to "stabilize the feet/lower extremity/spine" yadda yadda. What a convenient way to market orthotics to a broad spectrum of patients! I am completely unaware of any research that supports their claims and you are left trying to accomplish this with expensive, proprietary, ‘customized’ accommodative inserts made of one choice of material; EVA.
While I personally believe that there may be a link confirming this relationship in some of our patients, I would like to see more independent, well-designed RCT’s to affirm this. I notice that Dr. Christensen, who I have a great deal of respect for has listed Dr. Rothbart in his references, which raises an eyebrow and makes me question the credibility of that article.
Kevin Kirby wrote:
It would be difficult to say that foot orthoses by themselves "change posture" unless that means "foot posture" specifically. I do see in my clinic, however, that foot orthoses may dramatically change the angle and base of gait, the stride length, the length of the propulsive phase of gait and the position of the ankle, subtalar and midtarsal joints during both the stance and swing phases of walking gait.
Even though these changes in muscle moment arm lengths do occur sometimes due to a change in joint position with foot orthoses, the major mechanical effect of foot orthoses on the human body is rather to change the point of application, magnitude and temporal patterns of ground reaction forces acting on the plantar foot during weightbearing activities. This is the change in kinetics that is so important in producing the internal mechanical effects on the structural components of the foot and lower extremity that cause not only the change in kinematics we may or may not see, but also the change in subjective complaints that we very commonly see with foot orthoses.
I couldn't agree more with these statements by Kevin. After treating many patients over the years with both Chiropractic Manipulation for mechanical low back pain and foot orthoses, I cannot say with any real certainty that their orthoses are directly responsible for a reduction of low back symptoms (with one caveat; rigid cavus feet where the goal of orthotic therapy is to reduce heel strike forces via accommodation with softer materials).
If there is a link between flatfoot conditions, calcaneal eversion, navicular drop and mechanical low back pain I would like to see it proven and reproduced in RTC's. I feel that too many musculoskeletal practitioners espouse this link in order to justify affording a wider number of patient orthotics which are meant to address “postural distorsions" if you will and not specifically kinetic chain posture and kinematics, which is more global. Podiatrists have typically chosen orthoses as a conservative method to address pathology and symptoms of the feet and lower kinetic chain, which is a medically necessary pursuit and makes good clinical sense. Ancillary providers appear to have invaded the Podiatric turf and adopted a new lexicon to further their own goals
I was recently contacted by one of the Chiropractic publications to ask if I would participate in a survey of orthotic products we are using in practice. I think that they were surprised by my answers and approach because I flat out told them that I do not provide orthoses for low back pain (excepting the rigid cavus foot type) and do not adhere to one product, lab or material. They were also surprised that my orthosis business is built on referral from medical providers for medically necessary devices and seemed interested in learning more. I got the feeling that they were unaware what a Certified Pedorthist is and what their role in health care is.
One day and one mind at a a time...
Foot orthoses for LBP is a recurrent theme in many Chiropractic and Physical Therapy clinics but I haven't read any research strongly favoring this paradigm, can anyone reading this share this material if it is available?
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
Foot orthoses for LBP is a recurrent theme in many Chiropractic and Physical Therapy clinics but I haven't read any research strongly favoring this paradigm, can anyone reading this share this material if it is available?
I was actually being somewhat facetious. I am still waiting for the glittering epiphany from the companies who sell these ideas that insoles/orthoses can predictably and reliably negate mechanical low back pain due to overpronation (whatever that is).
I would also like to see them validate them for posture, proprioception and a receding hairline as well. They may even improve your sex life, who knows?
We should patent the "Little Blue Insoles" while we are at it .
__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
Dear Kevin Craig and David,
What a cool use of the world wide web, Im very greatful for the opportunity to chew the fat with leaders in such an interesting field.
Inreply to Craig I have dug out my very first biomechanics manual (1991) to explain my reasoning behind optimal muscle strength....I can see you roll your eyebrows now.......
"The force length curve for one sarcomere has been established"...Max isometric contraction on y axis and sarcomere length on the x axis with a bell curve type shape
" The amount of effective overlap between the actin and myosin filaments is related to the maximum strength of contraction"
I figure this means a really short or long muscle is not as strong.
Thats why I figured if you keep muscles in this position they had optimal output.
There is similar work done on the TMJ in Dentistry.
TO Kevin
has there been any studies able to measure hip Int Rotn/ Ext Rotation with and without orthotics? I wear orthotics to stop my piriformis from playing up and I thought it was because of this control. Also how do you measure kinematic changes in the clinic??
To David
The invasion of other healthcare professionals into the podiatrists domain of orthotic prescription was in Australia led by podiatrist owned companies. The invasion of therapists modalities has occured in all professions ....massage, dry needling, electro therapeutic agents,exercise prescription manipulation etc is not owned by any one profession anymore. Im sure this has many positive and negative effects but hopefully the sharing of ideas will in the long run benefit everybody.
Multi disiplinary approaches in my opinion is the best form of chronic pain Mx, as is the case in many clinics around Australia.
Thans for considering my blurb on such an interesting topic.
Regards
Gavin Johnston
I feel that too many musculoskeletal practitioners espouse this link in order to justify affording a wider number of patient orthotics which are meant to address “postural distorsions" if you will and not specifically kinetic chain posture and kinematics, which is more global.
Quote:
They may even improve your sex life, who knows?
No. We all know that they increase fertility right? And i can show strong anecdotal evidence of the deleterious effect babies have on your sex life.
I think the distinction between kinematic and kinetic change is important. I cannot remember the references but i'm pretty sure i remember that most studies show fairly minimal changes in leg rotation associated with use of orthotics.
Also need to be aware of the "spikeorthotic" element. Put something unfamilier in somebodies shoes and tell them its for posture and it is not surprising their posture changes.
I could show you a website with some dreadfully good before / after animations!
The problem with THAT is that its far harder to assess kinetic changes than kinematic changes and that makes it hard to know exactly what effect we are having. It is easy to reason a ratianale for how it might work, however LBP is a complex multifactoral condition including many psychosocial aspects and as such, responds rather well to a good placebo.
This, though it may seem unpaletable, is another explanation for the success of orthotics in LBP. Not saying it is mind you, just saying it would be another explanation for a pretty solid success rate.
TO Kevin
has there been any studies able to measure hip Int Rotn/ Ext Rotation with and without orthotics? I wear orthotics to stop my piriformis from playing up and I thought it was because of this control. Also how do you measure kinematic changes in the clinic??
Don't know of any orthosis studies that measure hip motion. However, that doesn't mean that they don't have a mechanical effect. We simply don't know the answer to that one. I estimate kinematic changes in the clinic visually.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Also need to be aware of the "spikeorthotic" element. Put something unfamilier in somebodies shoes and tell them its for posture and it is not surprising their posture changes.
Better be careful there, Robert. I have trademarked and patented the term "spikeorthotic" and anyone that uses this term again, without my express written permission, will be punished!!! (.....by being made to walk in a Sole Support super high arched insole on one foot and a Rothbart Proprioceptive insole on the other foot!)
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Don't know of any orthosis studies that measure hip motion. However, that doesn't mean that they don't have a mechanical effect. We simply don't know the answer to that one. I estimate kinematic changes in the clinic visually.
Better be careful there, Robert. I have trademarked and patented the term "spikeorthotic" and anyone that uses this term again, without my express written permission, will be punished!!! (.....by being made to walk in a Sole Support super high arched insole on one foot and a Rothbart Proprioceptive insole on the other foot!)
Come now, thats just being nasty!
You're right though. Credit where its due.
Regards
Robert
The "spikeorthotic brand and all subsideries, associates, versions, copies and rip offs remain the intellectual property of Prof K Kirby. No claim is made to ownership of this idea, nor is any right to manufacture said device inferred or claimed. The application of a drawing pin under the arch is not recommended without first understanding "ascending flinching patterns" training for which is available from prof Kirby's training company run by his associates "Fleece, Cripple and Sneer". For details of the spikeorthotic please send a SAE with a cheque for £300 to Kirby's Urinary Extraction Dept located in Cuba. The company does not indemnify you against loss of earnings, litigation or complaints arising from placing something pointy under somebodies foot and besides, its not like they can run after you is it!
Foot function and lower back pain can be very related, but one needs to think sagittally to see the connection. The papers below are for reference purposes,with the 2nd describing an almost 50% increase (7.5 to 13 degree average increase in hip joint extension during single support phase) when pre and post orthotic dispensing is measured.
Dananberg, HJ, Guiliano, M, “Chronic Lower Back Pain And It Response to Custom Foot Orthoses”, Journal of the American Podiatric Medical Association, 89:3 March, 1999 pp109-117
Dananberg, HJ, “Gait Style and Its Relevance in the Management of Chronic Lower Back Pain”, In Proceedings, 4th Interdisciplinary World Congress of Low Back & Pelvic Pain”, Ed, Vleeming, A, Mooney. V, Gracovetsky, S, Lee, D, etal, November 8-10, 2001, pp 225-230
Simon did cite a number of papers including the one from Canada. The Canadian paper did not find any significant change in hip ROM, but used subjects with "moderate to severe Fhl". While it did not described the joint measurements, from the sounds of it, used subjects with hallux limitus...and not the functional variety (which either fails to dorsiflex during gait or doesn't...there isn't a grading system that I am aware of). If these subjects did have arthritic joints, there is no wonder that they did not see an immediate change relative to orthotic useage.
While far too complex to describe here, the basic concept in LBP and gait involves the amount of hip extension present during single support phase. The failure to achieve a full 15 degrees leads to a situation where stress to the iliopsoas occurs and causes any number of problems. I have an online article available at http://www.vasylimedical.com/resources/articles.html. Scroll down to find the article on gait related lower back pain.
Thank you for the references. As a Chiropractor who's profession seems unerringly committed to providing orthoses based on spinal and pelvic complaints I am always searching for literature to support this. This is not because I prescribe accordingly, but because it is such a mainstream practice in my profession.
I would like to see this type of claim validated because it is such such a widely held belief and marketed by one company in particular. Of course the main problem is that the product that they are marketing en masse has limited clinical application as a truly custom, functional FO in my opinion.
Your comment regarding the sagittal plane does make a great deal of sense to me. I have read some of your papers on first ray function and adhere to many of you theories regarding the subject. I will read up on your studies regarding low back pain and foot function.
Do you believe that excessive pronation moments can lead to structural changes such as forward rotation of the pelvis, increased lumbar lordosis and disc wedging over time that cause LBP?
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"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright
While far too complex to describe here, the basic concept in LBP and gait involves the amount of hip extension present during single support phase. The failure to achieve a full 15 degrees leads to a situation where stress to the iliopsoas occurs and causes any number of problems. I have an online article available at http://www.vasylimedical.com/resources/articles.html. Scroll down to find the article on gait related lower back pain.
Howard
Howard,
You've known me long enough to know what's coming, so I'll come right out with it: how do you know that: "failure to achieve a full 15 degrees leads to a situation where stress to the iliopsoas occurs and causes any number of problems" ?
I did scan the link you suggested but the text was so small and my eyes are getting more tired with age that I may have missed the evidence you provided therein for this statement. Perhaps you could help me out here because I'm struggling to find a reference that demonstrates significant change in kinematics of the hip with foot orthoses of any kind . I take on board your point re: the Canadian study, perhaps if anyone knows the authors they could comment? Although it may be complicated, perhaps it might be helpful if could you explain how reduced hip extension results in increased stress to iliopsoas?
Cheers,
Simon
__________________ Science is the antidote to the poison of enthusiasm and superstition
The articles from the Vasyli website can be downloaded and printed....really saves your eyesight.
Hip extension allows for both longitudinal ground thrust as well as pre-load (read as: store potential energy) for swing phase. When single support ends with contralateral heel strike, the trailing limb IMMEDIATELY reverses from extension to flexion. This permits the limb to utilize its own weight to "collapse" into flexion, with the gastrox providing a burst from below, and the spinal engine driving this from above. Just at toeoff, the iliopsoas group fires and swing phase is begins. Its an elegant combination of energy storage/return with efficient muscle action.
The less rearward extension of the hip during single support phase however, the less forward flexion available during the preswing phase and thus a greater repetitive demand on the iliopsoas. Since the psoas actually originates from the disks and vertebra of the LS spine, the potential to create a repetitive and perpetual stress load is very real. Kapanji showed that when the femur is fixed and the iliopsoas fires, it is the LS spine that is rotated. Intervertebral disks are very strong to very vertical load, but far weaker to rotational shear. When this is repetitive, it can either weaken a disk, or act as Simons and Travell called a "perpetuating factor" when the disk is previously injured through other factors.
Those who treat lower back pain know it is characterized by many remissions and frequent exacerbations. Deyo showed a 71% recurrence rate in 12 months with subjects having a history of "back attacks" when localized methods of care are used to manage symptoms (ie, manipulation, PT, NSAID'S, etc.). When one considers gait style, and specifically, the maximum amount of hip extension during single support phase, the outcomes suggest a rather pronounced reduction in the recurrence rate. My 1999 JAPMA paper with Michelle Guiliano demonstrated only a 16% recurrence rate in a 12 to 24 month f/u period when CFO's made via sagittal plane principles are utilized. Since the entire focus is to improve extension mechanics, and this can be shown to dramatically decrease the recurrence rate, I do believe this shows a strong correlation to extension ability and CLBP.
The less rearward extension of the hip during single support phase however, the less forward flexion available during the preswing phase and thus a greater repetitive demand on the iliopsoas. Since the psoas actually originates from the disks and vertebra of the LS spine, the potential to create a repetitive and perpetual stress load is very real. Kapanji showed that when the femur is fixed and the iliopsoas fires, it is the LS spine that is rotated. Intervertebral disks are very strong to very vertical load, but far weaker to rotational shear. When this is repetitive, it can either weaken a disk, or act as Simons and Travell called a "perpetuating factor" when the disk is previously injured through other factors.
Whilst I generally agree with your saggital plane theory I find it difficult to follow your premise above, if it is correct to summarize as the following -
If the extension of the support leg is short then the psoas is required to work harder during the swing phase to achieve full flexion. The psoas works harder therefore the lumbar lordosis is increased. This increased lordosis increases local stress in the lumbar spine and results in pathological changes.
Then I query this in several ways
1) Surely taking short step tends to reduce gait forces in general
2) If there is a reduced hip extension then there is equivalent reduction in hip flexion and so there is no increase required in psoas action.
3) To see an increase in psoas action, by your proposition, would require a greater flexion phase relative to extension phase. I don't think this is seen, is it?
Can you clarify what you mean please
Cheers Dave Smith
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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
If the extension of the support leg is short then the psoas is required to work harder during the swing phase to achieve full flexion. The psoas works harder therefore the lumbar lordosis is increased. This increased lordosis increases local stress in the lumbar spine and results in pathological changes.
[some cut]
Can you clarify what you mean please
Cheers Dave Smith
Dave,
If you were to throw a baseball, or kick a soccer ball, you would either first reach back with your arm, or first pull your leg backwards into full extension and then kick or throw forwards. Both of these would be examples of pre-load. (Let's forget lordosis for the time being....to complex before we get the basics movement concepts down.)
During walking, the same is true. How do you develop sufficient speed for forward flexion (pre-swing acceleration), if insufficient pre-load of extension did not occur?
If the trailing limb begins its normal pre-swing motion from the extended position, then there is sufficient momentum...and at the time the psoas fires, the limb is already moving forward. If there is limited pre-load (read as: limited extension), then there is insufficient momentum of the pre-swing limb, and the psoas must initiate rather than perpetuate forward motion. Considering that each limb weighs 15% of body weight....this can become quite the stressful event. If this occurs over enough cycles....symptoms can and do occur.
It is really quite simple...and sounds like I did not explain myself clearly. Does this make sense now?
Foot function and low back pain
and mechanical low back pain I would like to see it proven and reproduced in RTC's. I feel that too many musculoskeletal practitioners espouse this link in order to justify affording a wider number of patient orthotics which are meant to address “postural distorsions" if you will and not specifically kinetic chain posture and kinematics, which is more global. Podiatrists have typically chosen orthoses as a conservative method to address pathology and symptoms of the feet and lower kinetic chain, which is a medically necessary pursuit and makes good clinical sense. Ancillary providers appear to have invaded the Podiatric turf and adopted a new lexicon to further their own goals 
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